- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,707.11 / $1,707.11 / $1,707.11
| Professional | | $1,707.11 | $1,707.11 | $1,707.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,675.42 / $3,989.66 / $10,166.60
| Facility | | $2,675.42 | $3,989.66 | $10,166.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,748.25 / $1,748.25 / $2,821.44
| Professional | | $1,748.25 | $1,748.25 | $2,821.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,675.42 / $3,989.66 / $10,166.60
| Facility | | $2,675.42 | $3,989.66 | $10,166.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,563.80 / $2,215.42 / $3,039.62
| Professional | | $1,563.80 | $2,215.42 | $3,039.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,713.97 / $1,713.97 / $1,713.97
| Professional | | $1,713.97 | $1,713.97 | $1,713.97 |